Katherine MOORE: So, there’s this piece — it’s probably my favorite one — choreographed by Lisa La Touche, who’s a really fabulous dancer and choreographer and musician. It’s called “Honey Something Blues.” We’ve actually performed a work-in-progress version of it a few times. And I just remember — one of those was this September. I knew the choreography so well. And I didn’t have to think about the steps at all while I was doing it. I was just listening to that music and feeling it in the body.
That’s Katherine Moore. She’s a tap dancer, who performs with the Lady Hoofers Tap Ensemble in Philadelphia. She’s also a cognitive psychologist at Arcadia University, right outside that city.
MOORE: I was just enjoying the way the music was combining with the sounds of our feet and also kind of that, like, proprioceptive, you know, that sensory feedback that I love about tap dancing. Because you’re not just hearing it. You’re, like, feeling the pounding, you know, on the floor. And it’s just pure fun.
Justin DIMICK: Honestly, the whole process of preparing to go to the operating room is a routine and it becomes ingrained in you as almost like a pre-O.R. meditation routine.
And that’s Dr. Justin Dimick, head of surgery at the University of Michigan.
DIMICK: Like, you take off your outside clothes and put on scrubs. You put on a surgical cap, you get your O.R. glasses on, and you walk in there and you scrub. And scrubbing — a lot of people will describe as kind of a preoperative clearing your head. You walk through the case. You visualize how it’s going to go. It also allows you to just kind of set aside everything else.
In some ways, surgery and dance are similar. Mostly because their performers may enter what’s known as a “flow state.” When you’re in flow, you’re in the zone. Your mind is fully immersed in, and absorbed by, the task at hand. The term “flow state” has also been described as “effortless attention.” You may lose awareness of time, and self. Artists have been known to enter flow, and so have athletes. For Katherine, if she’s practiced enough, the dance movements she performs on stage become almost automatic.
MOORE: You don’t have to think about it. You just do it. And then you can focus more on other performance aspects.
Justin has experienced something similar.
DIMICK: It really is like time melts away. Like, you can look up the clock and, you know, two hours has gone by in a flash. It’s almost trance-like and probably different for different people, but the scrub techs will often have to, like, shake me to get me to respond to some question they have, because I’m so focused on what I’m doing.
Intense focus is critical for a number of professions: pilots, accountants, scientists, and surgeons, of course. But very few people can achieve and maintain that kind of flow state on demand. People get distracted. They make mistakes. And in medicine, those mistakes can have consequences.
From the Freakonomics Radio Network, this is Freakonomics, M.D.
I’m Bapu Jena. I’m an economist and I’m also a medical doctor. Each episode, I dissect an interesting question at the sweet spot between health and economics.
Today on the show: how distractions in the medical world can impact patients … and what we might be able to do about it.
DIMICK: I thought you were going to ask me, should we have a policy that surgeons don’t operate on their birthdays?
MOORE: I mean, I really love rhythm.
That again, is the cognitive psychologist and tap dancer Katherine Moore. She’s been dancing for about 28 years; the past seven with a professional troupe in Philadelphia. That flow state she described earlier — it doesn’t always happen when she’s performing. Sometimes, things just get in the way.
MOORE: If you’re still in the stage of, “I was an understudy, and I had to learn this at the last minute, and I haven’t memorized everything perfectly,” I have to really pay a lot of goal-directed attention to my memory to try to remember what comes next in the piece.
When you have to think about every step, it takes away from other aspects of performing. And that applies to anything you’re trying to master.
MOORE: The dancer who’s still trying to remember the choreography isn’t going to be able to do the, like, acting, stage presence, because she’s focusing on the steps. And the surgeon who is focusing on the surgery shouldn’t be able to do something else at the same time. Because that’s going be a multitasking problem.
Fortunately, multitasking is one of Katherine’s research specialties.
MOORE: And really, I look at the limitations of multitasking under conditions of distraction. When you’re looking for more than one thing at a time, what happens when you get distracted?
Katherine co-authored a group of papers that looked at just this question. First, she had study participants sit at computers and play a game of sorts, where they had to search for letters that were two particular colors.
MOORE: Let’s say you’re looking for all the green letters and you’re looking for all the red letters. And you’re supposed to ignore all the other letters, but every once in a while, you know, maybe we’re showing you a green or red number. And those are considered distractors. And they capture your attention. And what we found is that actually people are pretty good at looking for the green letters and the red letters at the same time, as opposed to just looking for one color at a time. So, that’s great.
The problem is when distractors enter the picture. Katherine and her co-authors discovered that if a green number showed up on the screen while people were looking for green and red letters, it slowed them down. So, how might this play out in the real world? Well, say you’re in a grocery store.
MOORE: And let’s say you’re looking for, like, lemon and garlic as two of the items on your list. So, then all of a sudden you see, like, a yellow pepper. And it kind of looks like a lemon. And you’re like, “Oh wait, is that my lemon I’m looking for? Oh, no, it’s not. It’s just a yellow pepper.” So, that’s kind of an example of the costs of distraction in the context of multitasking.
Back to Katherine’s computer game. The researchers then measured just how much time people lost by looking at the distractors.
MOORE: Those distractor costs were, like, double or triple the size, compared to just looking for one thing. It’s kind of like, okay, driving feels like a pretty automatic task. A lot of times when we’re on the highway, you don’t have to think about it. You let your mind wander. It’s like, “Oh yeah, I feel comfortable getting on the phone while I’m driving. I could do that.” But once something happens, it’s not an automatic task anymore.
Distractions are everywhere. One way to deal with them might be to train ourselves to just multitask better. Katherine and her colleagues looked at that in their letter-searching study. Could the people in the study get better at multitasking over time?
MOORE: They could, and they couldn’t. And I would say the upshot is that they can’t. They got better at the very exact task of looking for the red and green letters. But once we said, “Okay, now let’s switch up the colors,” they were back to square one.
So, they could multitask a bit and they got better at it with some practice. But when she changed things just a little, you know — switching the colors to red and blue, for example — that multitasking skill faded away.
MOORE: There’s not really a training up of multitasking — getting good at multitasking.
Multitasking is a function of distraction. When something draws your eyes — or your mind — away from the task at hand, you’re forced to reckon with a number of things at once. And modern life demands that we multitask, nearly constantly. In a way, our brains are actually hardwired for this, whether we like it or not.
MOORE: We have this network called the attentional control network that is really what we think of when we think of focus. It’s about working towards a particular goal. And then there’s this other network of brain regions called the “default mode network” that’s really kind of your distractibility network. And it sounds like why would I even want that? But it actually is a really important aspect of attention. Because you want to be able to notice those external stimuli.
So, being able to focus is important but it’s also important to be able to be distracted. If you were so focused on a task that a burning house nearby didn’t catch your attention — didn’t distract you — that would be a problem.
Back to Justin Dimick, the surgeon at the University of Michigan. Justin told us earlier that sometimes, when he’s operating, he doesn’t notice when someone asks him a question because he’s so consumed with the task at hand.
DIMICK: Of course, you have to have some external situational awareness, but usually my scrub techs who know me well, will just kind of knock me on the shoulder and be like, “Hey, we asked you a question.”
MOORE: There is such a thing as being too focused. So, we really do need both networks. And they’re kind of always in competition with each other. It’s just about having some control about when you’re doing these things.
Meditation is one way to improve this control, according to Katherine. But meditating isn’t always an option, and doesn’t come naturally to everyone. And sometimes it’s just not possible to do one thing at a time — especially if you’re a physician on call at a busy hospital. You can’t just focus on one patient all day long, even if you’d really like to.
In medicine, and in general, distractions vary in their magnitude and nature. But even small distractions can have big implications. Let me give you an example. A few years ago, I co-authored a paper that looked at one very common, very human distraction that surgeons — and all of us — face, every year.
Yusuke TSUGAWA: In this study we try to understand patient mortality after surgery between surgeries performed on surgeons’ birthdays compared with other days of the year.
That’s one of my co-authors, Yusuke Tsugawa from U.C.L.A. Years ago, Yusuke was a student of mine, and he came to me with this really off-the-wall idea to look at whether patient outcomes would be worse when surgeons operated on their birthdays — the surgeons’ birthdays, not the patients’. For most adults, a birthday is a pretty small distraction, but it is a distraction. I thought this idea was plausible and that with large enough data, we might see something.
So, we looked. We used Medicare data from 2011 to 2014, where we had information on patients undergoing surgeries, the surgeons who operated on them, and critically: information about surgeons’ birthdays. The data on those birthdays were actually available in a federal database of physicians. You can look me up if you want to — but to make things easier — my birthday is July 17th.
TSUGAWA: We studied the data on about 1 million patients who underwent one of the 17 common surgical procedures. And we compared their mortality within 30 days of receiving the procedures.
The surgeries we looked at included heart valve procedures, appendectomies, and hip fracture operations, among others. We controlled for things like how sick the patients were, and we compared outcomes of patients who were operated on by a surgeon on their birthday with patients operated on by that same surgeon on other days of the year. It was a nice natural experiment because human beings have one birthday a year, and surgeons are, of course, human beings. And birthdays are random — meaning, they don’t just happen on certain days or times of year. And we showed that patients who underwent surgeries on a surgeon’s birthday were nearly identical in their characteristics to patients operated on by that same physician on other days of the year.
TSUGAWA: We still found that patient mortality was about 23 percent higher when the procedure is performed on a surgeon’s birthday compared with other days of the year.
That’s a really striking finding — even this small, benign distraction for the surgeon significantly increased the patient’s chance of dying. We also ran a bunch of what are called “robustness checks” to test our findings and make sure that they weren’t due to random chance. For example, we checked to see if there was any difference in outcomes on surgeons’ half birthdays — there wasn’t. We also did an analysis where we assigned surgeons a random fake birthday — something we just pulled out of a hat — to see if there was any effect on patient mortality when using those fake birthdays. If we saw an effect, it would suggest that what we’d found earlier was just a random coincidence. But we didn’t find anything there.
When we were convinced that we might be onto something, we dug a little bit deeper into the birthday effect. For example, we looked at whether the birthday effect was larger on certain birthdays, like a surgeon’s 50th or 60th birthday, because maybe those birthdays would be more distracting to a surgeon and harm patients even more. We didn’t find any evidence of that. We also looked at whether the birthday effect was larger when a surgeon’s birthday fell on a Friday, because we thought surgeons might be more willing to celebrate big on a Friday night compared to any other weekday. Again, no additional effect there.
So, we had this interesting but strange finding that patients seemed to do worse when operated on by a surgeon who had a birthday that day. But our data wasn’t able to tell us why this was happening. Maybe surgeons felt rushed to wrap up for the day and made some mistakes as a result of hurrying. Or maybe they were less attentive to complications that occurred in the hours following the surgery. It’s hard to say for sure, but distraction, of some form, is a real possibility here. So, does this mean it’s less safe for a patient to undergo a procedure on their surgeon’s birthday? Could doctors get too distracted?
TSUGAWA: On average, it seems birthdays has some influence on surgeon’s performance, but it doesn’t mean it is the case for every single surgeon. Patients, at this point, don’t have to be too concerned about whether their procedure is performed on surgeons’ birthday or not. We should focus on making sure that work environment is comfortable enough for surgeons to perform well regardless of the distractions they have.
Before we go to the break, I want to let you know there’s a new show coming soon from the Freakonomics Radio Network.
WOMAN 1: Are the names we give our dogs meaningful to them?
WOMAN 2: Pop Tart the Pitbull — she was thrilled by the sound of her own name. It was one of those things that really stuck in my brain — just how much she enjoyed listening.
Make sure you stick around until the very end of this show to hear the full preview. Coming up: Dealing with distraction is just one element of safety in the operating room. How else can surgeons improve patient outcomes? And, what does the surgeon Justin Dimick think about our birthday paper?
DIMICK: As someone who is approaching 50, like, I don’t really care about my birthday.
* * *
I’m Bapu Jena, and this is Freakonomics, M.D.
DIMICK: Most surgeons on their birthdays, I think they’d be like, “I’m so excited. Happy birthday to me, I get to be at the operating room!”
That again, is Justin Dimick, chair of surgery at the University of Michigan. By the way, his birthday is coming up — on June 1st.
DIMICK: As someone who is approaching 50, like, I don’t really care about my birthday. And in fact, my wife told me for her 50th birthday that she wants for a birthday present for me to not to remind her that she’s turning 50. So, it’s an interesting notion that you might be distracted by that.
As we heard him describe earlier, Justin focuses really intensely when he’s operating, to the point that other people in the room have to shake him to get his attention. In that scenario, you might think that Justin couldn’t be distracted by anything. But, as a busy surgeon at a busy hospital, distractions are unavoidable. And, sometimes, uncontrollable.
DIMICK: I think distractions are usually things that are happening where somebody will come in and say, you know, “Oh, there’s another patient in the E.R. that you need to see.” Because you have to step back and, like, process that, or, you know, your patient upstairs also needs to go back to the O.R. Those things can be distractions, because it pulls you out of that flow state because you need to make decisions about another individual.
JENA: But I’ll tell you, so you gave me an idea for a study, because your outcomes for a given patient may be negatively affected if you have another patient who is experiencing bad outcomes. You know, in theory you might be able to look at this sort of question in some of the surgical registry databases that exist. You could see if you operated on a patient in the morning and they have to be brought back to the O.R. later in the day — whether the patients who are operated on right after that second patient have worse outcomes.
DIMICK: That’s an interesting study.
JENA: You hear — you heard it here first and I got it from you.
DIMICK: Another hypothesis-generating, uh, study.
JENA: Exactly. Yeah. So, are there things that you do to limit distraction?
DIMICK: A lot of it is just making sure that anything external is kind of taken care of before you go to the O.R. You don’t want to walk to the door with things hanging over you. And if that means calling in a partner to help with a different patient or a different case or something like that, or calling in your backup, I think those are really important to do. Especially, you know, imagine you’re a trauma surgeon or the vascular surgeon on call or something like that, where you have two life-threatening emergencies playing out in parallel. And those priorities can change, and you need somebody else available to help with that. I thought you were going to ask me, should we have a policy that surgeons don’t operate on their birthdays?
JENA: Oh, should we? I don’t know. I, I wouldn’t take that from our paper, by the way.
DIMICK: Yeah, I thought you might ask me that. So, my answer to that would be this is, I think, 0.2 percent of all the surgeries that you looked at?
JENA: Yeah, very small.
DIMICK: Yeah, and we don’t have great policies to address the other 99.8 percent.
Justin’s point is that we should focus less — or maybe not at all, really — on the small percentage of surgery outcomes impacted by surgeons operating on their birthdays and instead, focus more on improving surgical outcomes overall. In fact, it’s what his research is all about.
DIMICK: There were a lot of people focusing on those topics in medicine, but there weren’t a lot of practicing surgeons focused in those areas. So, I thought it was worth having a surgeon at the table in those conversations. A lot of those policies didn’t really move the needle for quality. So, I started to think about how — as a surgeon who’s engaging with other surgeons how we can leverage data and improve care ourselves
Justin is part of a group of surgeons and hospitals in Michigan that are working to improve surgical outcomes in bariatric surgery. They had already taken some basic steps to accomplish this, like standardizing care before and after procedures to reduce complications.
DIMICK: We thought that we had squeezed all of the improvement that we could out of pre- and post-operative care, but there’s obviously still complications We were like, geez, we need to get into the operating room itself and see if there’s a way that we can measure the quality of the operation and set about improving it. And so, we started collecting videos.
What they did was super clever. They had surgeons in the state send a video of themselves performing a gastric bypass procedure, which is a common weight-loss surgery. And then, they had other doctors rate the videos.
DIMICK: So, what do you think they sent? Like, the best one they’ve ever done basically, right? We found quite a bit of variation in other physicians rating their skill. And that’s kind of interesting, right? Kind of expected that skill would vary. And we found a really strong effect of surgeon skill as rated by your peers and how that impacts outcomes. Now, when you present this kind of data at a conference, everyone comes to the mic and they say, you know, “Thanks again for showing us the obvious — that good surgeons are good, right?” And I answered that by saying, “Listen, that’s not what we showed. We showed that we can measure good in a reproducible, reliable way, and that measurement of what is good correlates with an important outcome.”
JENA: When I first saw that study, what I thought about was, you know, imagine that you’re a college coach and you’re being sent recruitment videos by high school athletes. That video is not a random representation of that high school athlete’s performance. It’s the best that they’ve ever performed, probably. But then you make an assessment of what this person is ultimately going to be like. And the analogy here is that you have one snapshot of a surgeon operating. You can make an assessment of whether or not they look like a good or bad surgeon based on the skill that’s exhibited in that video. And then you show that that assessment is correlated with their actual outcomes, which is quite interesting. So, then what did you do about that finding?
DIMICK: Think about a surgeon trying to learn a new procedure, right? We don’t really have a great way to accelerate the learning curve. Learning curve is a euphemism. It really is an unnecessary patient harm curve. If you’re a surgeon and you want to learn something new, what you do is you go to a weekend course. You may do it a few times proctored. So, there’s a huge gap and there’s not great ways to improve surgeon skills. So, we kind of went where all health services researchers go for good ideas. We went to The New Yorker.
In 2011, the surgeon and writer Atul Gawande published an article in The New Yorker magazine called “Personal Best.” In it, he talks about the idea of coaching not just for sports, but for other professions too, like doctors and surgeons. Gawande describes the work of Dr. Caprice Greenberg, a health services researcher and surgeon now at the Medical College of Georgia, who pioneered the use of video in the operating room.
DIMICK: And she had been working with sport coaches, music coaches, and had developed a surgical coaching model. And we conducted a two-year surgical coaching program where we had coachees enroll and bring a video and sit down for an hour to 90 minutes with a trained surgical coach to get feedback on their technical skill. And we saw about a 14 percent improvement in efficiency. So, O.R. time improved.
JENA: Interesting. So, the idea is like, can you coach doctors? And I mean, the same would probably be true outside of surgery as well. It’s a different type of coaching. I mean, you’re presumably coaching a lot on the technical aspects of the surgery.
DIMICK: We think of it as technical, but a lot of it is how you set things up. It’s strategy. Most surgeons can do all of the things that they need to do. The question is how do you position it? How do you sequence them? How do you move from step to step? So, it’s still very much cognitive coaching.
JENA: Why don’t we see more coaching?
DIMICK: Yeah, that’s a great question. And this gets into one of my favorite topics, which is the surgical personality. And of course, the surgical personality is: there’s a stereotype and it is a stereotype that was earned. And I think to the extent to which we can move away from that and be more humble and accepting of feedback, I think that’s where coaching comes in A master surgeon gets there by constantly examining their practice and asking for help. And not everybody gets there. And I think it’s the people that naturally know to do that, really, really hone their craft.
JENA: Why did you become a surgeon?
DIMICK: I love to work with my hands. It’s —
JENA: You could have become a carpenter.
DIMICK: Well, I went to medical school because I wanted to serve people and help them with their health and then gravitated to surgery because I like completing little projects that help people. Some days it’s a tough job and you take a lot on to be a surgeon. There’s this sort of immediacy of using trauma on the human body to fix disease. when you do something life-threatening to a patient to hopefully extend their life or improve their quality of life.
Justin’s work has explored shifting the culture within surgery, to look inward to improve patient outcomes. But outside factors, like distractions, still happen, on both individual and system levels. Surgeons can try to tune them out, but they never quite disappear. And distractions don’t just affect surgeons. In fact, that’s one reason we have checklists and protocols in place across all sorts of professions. There’s no perfect solution to the problem of distraction, but there is some helpful advice, courtesy of our tap-dancing friend, the cognitive neuroscientist Katherine Moore.
MOORE: Really the best way to overcome multitasking is to find a way to schedule the tasks to do them on their own. So, lots of things that come easily to us still aren’t automatic. And you shouldn’t try to do two at a time.
Well, I’m about to try to do two things at a time. I’m going to wrap up this episode, and also, let you know what’s coming up next week on Freakonomics, M.D.
Fear can be a powerful thing. But, can we use it to make people healthier?
FAIRCHILD: The more fear you use, the bigger the effect that you have.
And, does fear have its limits?
WORSHAM: You would think that if you knew how bad something could be that you, as a parent, would want to make sure that your child avoided that bad thing.
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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. This episode was produced by Mary Diduch and mixed by Eleanor Osborne. Our senior producer is Julie Kanfer. Our staff also includes Alison Craiglow, Greg Rippin, Gabriel Roth, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, Jacob Clemente, Alina Kulman, and Stephen Dubner. Our music was composed by Luis Guerra. To find a transcript, links to research, and a newsletter sign-up, go to Freakonomics dot com. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.
JENA: Do you listen to music in the O.R., or no?
DIMICK: I am not someone who has a playlist for the O.R.
JENA: So, it hasn’t become mandatory to listen to Freakonomics, M.D. in the O.R.?
DIMICK: Well, that would be a distraction.
JENA: That’d be a distraction. Exactly. A pleasant distraction. Yeah.
- “Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions,” by Caprice C. Greenberg, Mary E. Byrnes, Tedi A. Engler, Sudha Pavuluri R. Quamme, Jyothi R. Thumma, and Justin B. Dimick (Annals of Surgery, 2021).
- “Patient Mortality After Surgery on the Surgeon’s Birthday: Observational Study,” by Hirotaka Kato, Anupam B. Jena, and Yusuke Tsugawa (BMJ, 2020).
- “Practice Reduces Set-Specific Capture Costs Only Superficially,” by Katherine Sledge Moore and Elizabeth A. Wiemers (Attention, Perception, & Psychophysics, 2018).
- “Surgical Skill and Complication Rates After Bariatric Surgery,” by John D. Birkmeyer, Jonathan F. Finks, Amanda O’Reilly, Mary Oerline, Arthur M. Carlin, Andre R. Nunn, Justin Dimick, Mousumi Banerjee, and Nancy J. O. Birkmeyer (The New England Journal of Medicine, 2013).
- “Personal Best,” by Atul Gawande (The New Yorker, 2011).
- “Involuntary Transfer of a Top-Down Attentional Set Into the Focus of Attention: Evidence From a Contingent Attentional Capture Paradigm,” by Katherine Sledge Moore and Daniel H. Weissman (Attention, Perception, & Psychophysics, 2010).